Drug delivery systems for cyclosporine: achievements and complications

Bio-enabling strategies to mitigate the pharmaceutical food effect: a mini review

The concomitant administration of oral drugs with food can result in significant changes in bioavailability, leading to variable pharmacokinetics and considerable clinical implications, such as over- or under-dosing. Consequently, there is increasing demand for bio-enabling formulation strategies to reduce variability in exposure between the fasted and fed state and/or mitigate the pharmaceutical food effect. The current review critically evaluates technologies that have been implemented to overcome the positive food effects of pharmaceutical drugs, including, lipid-based formulations, nanosized drug preparations, cyclodextrins, amorphisation and solid dispersions, prodrugs and salts. Additionally, improved insight into preclinical models for predicting the food effect is provided. Despite the wealth of research, this review demonstrates that application of optimal formulation strategies to mitigate the positive food effects and the evaluation in preclinical models is not a universal approach, and improved standardisation of models to predict the food effects would be desirable. Ultimately, the successful reformulation of specific drugs to eliminate the food effect provides a panoply of advantages for patients with regard to clinical efficacy and compliance.

Molecular Dynamics Simulations and Experimental Results Provide Insight into Clinical Performance Differences between Sandimmune® and Neoral® Lipid-Based Formulations

OBJECTIVE

Molecular dynamics (MD) simulations provide an in silico method to study the structure of lipid-based formulations (LBFs) and the incorporation of poorly water-soluble drugs within such formulations. In order to validate the ability of MD to effectively model the properties of LBFs, this work investigates the well-known cyclosporine A formulations, Sandimmune® and Neoral®. Sandimmune® exhibits poor dispersibility and its absorption from the gastrointestinal tract is enhanced when administered after food, whereas Neoral® disperses comparatively well and shows no food effect.

METHODS

MD simulations were performed of both LBFs to investigate the differences observed in fasted and fed conditions. These conditions were also tested using an in vitro experimental model of dispersion and digestion.

RESULTS

These MD simulations were able to show that the food effect observed for Sandimmune® can be explained by large changes in drug solubilization on addition of bile. In contrast, Neoral® is well dispersed in water or in simulated fasted conditions, and this dispersion is relatively unchanged on moving to fed conditions. These differences were confirmed using dispersion and digestion in vitro experimental model.

CONCLUSIONS

The current data suggests that MD simulations are a potential method to model the fate of LBFs in the gastrointestinal tract, predict their dispersion and digestion, investigate behaviour of APIs within the formulations, and provide insights into the clinical performance of LBFs.

Pharmaceutical Formulations with P-Glycoprotein Inhibitory Effect as Promising Approaches for Enhancing Oral Drug Absorption and Bioavailability

P-glycoprotein (P-gp) is crucial in the active transport of various substrates with diverse structures out of cells, resulting in poor intestinal permeation and limited bioavailability following oral administration. P-gp inhibitors, including small molecule drugs, natural constituents, and pharmaceutically inert excipients, have been exploited to overcome P-gp efflux and enhance the oral absorption and bioavailability of many P-gp substrates. The co-administration of small molecule P-gp inhibitors with P-gp substrates can result in drug–drug interactions and increased side effects due to the pharmacological activity of these molecules. On the other hand, pharmaceutically inert excipients, including polymers, surfactants, and lipid-based excipients, are safe, pharmaceutically acceptable, and are not absorbed from the gut. Notably, they can be incorporated in pharmaceutical formulations to enhance drug solubility, absorption, and bioavailability due to the formulation itself and the P-gp inhibitory effects of the excipients. Different formulations with inherent P-gp inhibitory activity have been developed. These include micelles, emulsions, liposomes, solid lipid nanoparticles, polymeric nanoparticles, microspheres, dendrimers, and solid dispersions. They can bypass P-gp by different mechanisms related to their properties. In this review, we briefly introduce P-gp and P-gp inhibitors, and we extensively summarize the current development of oral drug delivery systems that can bypass and inhibit P-gp to improve the oral absorption and bioavailability of P-gp substrates. Since many drugs are limited by P-gp-mediated efflux, this review is helpful for designing suitable formulations of P-gp substrates to enhance their oral absorption and bioavailability.

Nanoformulation strategies for improving intestinal permeability of drugs: A more precise look at permeability assessment methods and pharmacokinetic properties changes

The therapeutic efficacy of orally administered drugs is often restricted by their inherent limited oral bioavailability. Low water solubility, limited permeability through the intestinal barrier, instability in harsh environment of the gastrointestinal (GI) tract and being substrate of the efflux pumps and the cytochrome P450 (CYP) can impair oral drug bioavailability resulting in erratic and variable plasma drug profile. As more drugs with low membrane permeability are developed, new interest is growing to enhance their intestinal permeability and bioavailability. A wide variety of nanosystems have been developed to improve drug transport and absorption. Sufficient evidence exists to suggest that nanoparticles are able to increase the transepithelial transport of drug molecules. However, key questions remained unanswered. What types of nanoparticles are more efficient? What are preclinical (or clinical) achievements of each type of nanoformulation in terms of pharmacokinetic (PK) parameters? Addressing this issue in this paper, we have reviewed the current literature regarding permeability enhancement, permeability assessment methods and changes in PK parameters following administration of various nanoformulations. Although permeability enhancement by various nanoformulations holds great promise for oral drug delivery, many challenges still need to be addressed before development of more clinically successful nanoproducts.

A Polyvinylpyrrolidone-Based Supersaturable Self-Emulsifying Drug Delivery System for Enhanced Dissolution of Cyclosporine A

A novel supersaturable self-emulsifying drug delivery system (S-SEDDS) of cyclosporine A (CyA)—a poorly water-soluble immunosuppressant—was constructed in order to attain an apparent concentration–time profile comparable to that of conventional SEDDS with reduced use of oil, surfactant, and cosolvent. Several hydrophilic polymers, including polyvinylpyrrolidone (PVP), were employed as precipitation inhibitors in the conventional SEDDS, which consists of corn oil-mono-di-triglycerides, polyoxyl 40 hydrogenated castor oil, ethanol, and propylene glycol. PVP-incorporated pre-concentrate (CyA:vehicle ingredients:PVP = 1:4.5:0.3 w/v/w) spontaneously formed spherical droplets less than 120 nm within 7 min of being diluted with water. In an in vitro dialysis test in a biorelevant medium such as simulated fed and/or fasted state intestinal and/or gastric fluids, PVP-based S-SEDDS exhibited a higher apparent drug concentration profile compared to cellulose derivative-incorporated S-SEDDS, even displaying an equivalent concentration profile with that of conventional SEDDS prepared with two times more vehicle (CyA:vehicle ingredients = 1:9 w/v). The supersaturable formulation was physicochemically stable under an accelerated condition (40 °C/75% RH) over 6 months. Therefore, the novel formulation is expected to be a substitute for conventional SEDDS, offering a supersaturated state of the poorly water-soluble calcinurin inhibitor with a reduced use of vehicle ingredients.

Preparation and evaluation of cyclosporin A-containing proliposomes: a comparison of the supercritical antisolvent process with the conventional film method

Objectives

The objectives of this study were to prepare cyclosporin A (CsA)-containing proliposomes using the supercritical antisolvent (SAS) process and the conventional thin film method for the comparative study of proliposomal formulations and to evaluate the physicochemical properties of these proliposomes.

Methods

CsA-containing proliposomes were prepared by the SAS process and the conventional film method, composed of natural and synthetic phospholipids. We investigated particle size, polydispersity index, and zeta potential of CsA-containing proliposomes. In addition, both production yield and entrapment efficiency of CsA in different proliposomes were analyzed. Physicochemical properties of CsA-containing proliposomes were also evaluated, using differential scanning calorimetry and X-ray diffraction. The morphology and size of CsA-containing proliposomes were confirmed, using scanning electron microscopy. We checked the in vitro release of CsA from CsA-containing proliposomes prepared by different preparation methods, comparing them with Restasis^® as a positive control and the stability of SAS-mediated proliposomes was also studied.

Results

CsA-containing proliposomes formed by the SAS process had a relatively smaller particle size, with a narrow size distribution and spherical particles compared with those of conventionally prepared proliposomes. The yield and entrapment efficiency of CsA in all proliposomes varied from 85% to 92% and from 86% to 89%, respectively. Differential scanning calorimetry and X-ray diffraction studies revealed that the anhydrous lactose powder used in this formulation retained its crystalline form and that CsA was present in an amorphous form. Proliposome powders were rapidly converted to liposomes on contact with water. The in vitro release study of proliposomal formulations demonstrated a similar pattern to Restasis^®. The SAS-mediated CsA-containing proliposomes were stable on storage, with no significant changes in particle size, polydispersity index, and entrapment efficiency.

Conclusion

These results show promising features of CsA-containing proliposomal formulations, using the SAS process for the large-scale industrial application.

Novel formulations for antimicrobial peptides

Peptides in general hold much promise as a major ingredient in novel supramolecular assemblies. They may become essential in vaccine design, antimicrobial chemotherapy, cancer immunotherapy, food preservation, organs transplants, design of novel materials for dentistry, formulations against diabetes and other important strategical applications. This review discusses how novel formulations may improve the therapeutic index of antimicrobial peptides by protecting their activity and improving their bioavailability. The diversity of novel formulations using lipids, liposomes, nanoparticles, polymers, micelles, etc., within the limits of nanotechnology may also provide novel applications going beyond antimicrobial chemotherapy.

Formulation strategies to improve oral peptide delivery

Delivery of peptides by the oral route greatly appeals due to commercial, patient convenience and scientific arguments. While there are over 60 injectable peptides marketed worldwide, and many more in development, most delivery strategies do not yet adequately overcome the barriers to oral delivery. Peptides are sensitive to chemical and enzymatic degradation in the intestine, and are poorly permeable across the intestinal epithelium due to sub-optimal physicochemical properties. A successful oral peptide delivery technology should protect potent peptides from presystemic degradation and improve epithelial permeation to achieve a target oral bioavailability with acceptable intra-subject variability. This review provides a comprehensive up-to-date overview of the current status of oral peptide delivery with an emphasis on patented formulations that are yielding promising clinical data.

Characterization and stability studies of a novel liposomal cyclosporin A prepared using the supercritical fluid method: comparison with the modified conventional Bangham method

A novel method to prepare cyclosporin A encapsulated liposomes was introduced using supercritical fluid of carbon dioxide (SCF-CO₂) as an antisolvent. To investigate the strength of the newly developed SCF-CO₂ method compared with the modified conventional Bangham method, particle size, zeta potential, and polydispersity index (PDI) of both liposomal formulations were characterized and compared. In addition, entrapment efficiency (EE) and drug loading (DL) characteristics were analyzed by reversed-phase high-performance liquid chromatography. Significantly larger particle size and PDI were revealed from the conventional method, while EE (%) and DL (%) did not exhibit any significant differences. The SCF-CO₂ liposomes were found to be relatively smaller, multilamellar, and spherical with a smoother surface as determined by transmission electron microscopy. SCF-CO₂ liposomes showed no significant differences in their particle size and PDI after more than 3 months, whereas conventional liposomes exhibited significant changes in their particle size. The initial yield (%), EE (%), and DL (%) of SCF-CO₂ liposomes and conventional liposomes were 90.98 ± 2.94, 92.20 ± 1.36, 20.99 ± 0.84 and 90.72 ± 2.83, 90.24 ± 1.37, 20.47 ± 0.94, respectively, which changed after 14 weeks to 86.65 ± 0.30, 87.63 ± 0.72, 18.98 ± 0.22 and 75.04 ± 8.80, 84.59 ± 5.13, 15.94 ± 2.80, respectively. Therefore, the newly developed SCF-CO₂ method could be a better alternative compared with the conventional method and may provide a promising approach for large-scale production of liposomes.

A water-soluble prodrug of cyclosporine A for ocular application: a stability study

UNIL088 is a water-soluble prodrug of cyclosporine A (CsA) developed for topical eye delivery. Such a prodrug has to fulfil two paradoxical requirements as it must be rapidly hydrolysed under physiological conditions but also retain a long shelf-life in aqueous media. This study has been conducted to explore the stability of UNIL088 formulated as an eyedrop solution. The stability study of the prodrug was performed over a pH range of 5-7 at 20 degrees C and at various ionic strengths. The molecule was more stable at pH 5 than at pH 7 with conversion rate constant of 3.2 x 10(-3) and 26.0 x 10(-3)days(-1), respectively. The effect of temperature was studied at four different temperatures and activation energy was determined. Conversion of UNIL088 followed a pseudo-first-order kinetic with an activation energy of 79.4 kJ mol(-1). Due to its low solubility, CsA generated precipitated in the solution. The average size of CsA precipitates, determined by photon spectroscopy, was 0.22 and 1.08 microm at 7 and 14 days, respectively. The hydrolysis mechanism was partially elucidated by identification of the intermediate pSer-Sar-CsA.

Novel gels and their dispersions--oral drug delivery systems for ciclosporin

Amphiphilogels (gels that consist solely of surfactants) and gel-based emulsion (GEM) formulations (solutions that gel upon incorporation of small amounts of water) were investigated as oral delivery vehicles for ciclosporin A, in in vivo experiments in Beagle dogs. Both systems represent essentially self-dispersing non-lipidic drug delivery systems based on amphiphilic surfactants. Three different amphiphilogels (hydrophobic, hydrophilic and hydrophilic gel containing ethanol), the aqueous dispersions of the latter two amphiphilogels and of two GEM formulations were tested to determine the influence of (i) gel hydrophilicity/hydrophobicity, (ii) presence of ethanol, (iii) pre-dispersion of gels into aqueous medium prior to oral administration and (iv) size of dispersions, on drug absorption. It was found that all the formulations tested, except for the hydrophilic amphiphilogel and its aqueous dispersion, were bioequivalent to Neoral, the commercially available preparation. High drug absorption from the bioequivalent formulations was thought to be due to the fact that following oral administration, ciclosporin remained in a soluble form, hence was available for absorption, despite relatively large droplet sizes of the formulations. The hydrophilic gel and its dispersion allowed less drug absorption; this was assigned to the fact that, when the hydrophilic amphiphilogel contacted an aqueous medium, there were no lipophilic domains in which the drug could remain soluble. It is possible that some drug precipitated out and was unavailable for absorption.

Oral evaluation in rabbits of cyclosporin-loaded Eudragit RS or RL nanoparticles

The hydrophobic cyclic undecapeptide cyclosporin A (CyA) used in the prevention of graft rejection and in the treatment of autoimmune diseases was encapsulated by nanoprecipitation within non-biodegradable polymeric nanoparticles. The effect of polymers (Eudragit RS or RL) and additives within the alcoholic phase (fatty acid esters and polyoxyethylated castor oil) on the size, zeta potential and the encapsulation efficiency of the nanoparticles was investigated. The mean diameter of the various CyA nanoparticles ranged from 170 to 310 nm. The size as well as the zeta potential increased by adding fatty acid ester and polyoxyethylated castor oil within the organic phase. No significant differences in surface potential were observed for all formulations tested. Probably due to the very low water solubility of the drug, high encapsulation efficiencies were observed in a range from 70 to 85%. The oral absorption of CyA from these polymeric nanoparticles was studied in rabbits and compared to that of Neoral capsule. Based on comparison of the area under the blood concentration-time curve values, the relative bioavailability of CyA from each nanoparticulate formulation ranged from 20 to 35%.

Cyclosporin Nanoparticulate Lipospheres for Oral Administration

Cyclosporin is a first line immunosuppressive drug used to prevent transplant rejection and to treat autoimmune diseases. It is a hydrophobic cyclic peptide built from nonmammalian amino acids with low oral bioavailability. The aim of this study was to develop an oral delivery system for cyclosporin A (CyA) and investigate the effect of composition and particle size of the CyA lipid nanoparticles (lipospheres) on the oral bioavailability of this drug. Dispersible concentrated oil formulations that upon mixing in water spontaneously form a nanodispersion were developed. The concentrated oil formulations were clear solutions composed of the drug, a solid triglyceride, a water miscible organic solvent, and a mixture of surfactants and emulsifiers. The activity of the formulated cyclosporin was determined in vitro following the effect on the proliferation of T cells. The oral bioavailability was determined on humans following the cyclosporin blood levels after oral intake of formulated cyclosporin. Cyclosporin dispersion systems resulting in particle size of 25 to 400 nm were prepared from acceptable pharmceutical components. The composition of the surfactants and emulsifiers, the lipid core component, and the amount and type of the water miscible organic solvent N-methylpyrrolidone (NMP) and alcohols had a strong effect on the particle size of the dispersions. All formulations were reproducible and stable at room temperature for at least 6 months, with full activity of cyclosporin retained. Human oral bioavaiability study indicated a correlation between the AUC and C(max) and the particle size of the dispersion. A C(max) of approximately 1300 ng/mL was found after 2 h of oral intake of four capsules, each loaded with 50 mg cyclosporin.

Gel-microemulsions as vaginal spermicides and intravaginal drug delivery vehicles

There is a need for novel formulations to improve the bioavailability through the vaginal/rectal mucosa of microbicidal drug substances against sexually transmitted diseases. In addition, there is a need for more effective and less toxic vaginal spermicides. Here we review our recent discovery of novel gel-microemulsions (GM) as nontoxic, dual-function intravaginal spermicides, which can be used as delivery vehicles for lipophilic drug substances targeting sexually transmitted pathogens. We describe the formulation and biologic properties of 2 novel, submicron-particle-size GMs, GM-4 and GM-144, which were prepared from commonly available pharmaceutical excipients. These GMs comprising oil-in-water microemulsion and polymeric hydrogels were designed to solubilize lipophilic antiviral/antimicrobial agents and exhibited rapid spermicidal activity in human semen. Preclinical studies comparing the in vivo contraceptive efficacy of GM-4 and GM-144 versus nonoxynol-9-based detergent spermicide (Gynol II) in the rigorous rabbit model confirmed the potent contraceptive activity of these GMs. Unlike nonoxynol-9, repeated intravaginal applications of GM-4 and GM-144 in the rabbit vaginal irritation test were not associated with local inflammation or damage of the vaginal mucosa or epithelium. Furthermore, in short-term toxicity studies performed in mice, repetitive intravaginal application of spermicidal GM-4 and GM-144 for up to 13 weeks was not associated with any local, systemic, or reproductive toxicity. Spermicidal GMs have unprecedented potential as dual function microbicidal contraceptives to improve vaginal bioavailability of poorly soluble antimicrobial agents without causing significant vaginal damage.

Preparation and evaluation of biphenyl dimethyl dicarboxylate microemulsions for oral delivery

To improve the solubility and bioavailability of poorly water-soluble biphenyl dimethyl dicarboxylate (BDD), a drug used in treating liver diseases, a premicroemulsion concentrate composed of oil, surfactant, and cosurfactant for oral administration of BDD was prepared, and its physicochemical properties and the pharmacokinetic parameters of BDD were evaluated. Among the non-ionic surfactants and oils studied, Tween 80, which led to the highest solubility of BDD (109.7 microg/ml), and Neobee M-5((R)) were chosen for preparing a premicroemulsion concentrate. At the 2:1 ratio of Tween 80 to Neobee M-5((R)), the solubility of BDD increased 7-fold compared with that at the ratio of 1:4. The solubility of BDD was further improved by the addition of triacetin used as a cosurfactant. Droplet size of BDD microemulsion comprising Tween 80 and Neobee M-5((R)) at the ratio of 2:1, and 35% of triacetin, was kept constant both in distilled water and artificial gastric fluid without pepsin (pH 1.2) throughout 120-min incubation period. BDD in premicroemulsion concentrate rapidly dissolved whereas the mixture of BDD and calcium-carboxymethylcellulose (Ca-CMC) (2:1) and BDD powder hardly dissolved during 120-min incubation. About 50% of BDD in premicroemulsion concentrate dissolved within 10 min. AUC(0-->24 h) and the mean maximum plasma level (C(max)) of BDD after oral administration of premicroemulsion concentrate in rats were 5- and 9.8-fold higher, respectively, than those of BDD with Ca-CMC. These results demonstrate that premicroemulsion concentrate of BDD composed of Tween 80 and Neobee M-5((R)) at the ratio of 2:1, and 35% of triacetin, greatly enhances the bioavailability of BDD after the dose, possibly due to the increase in solubility and immediate dispersion of drug in the gastrointestinal tract. Thus, this system may provide a useful dosage form for oral intake of a water-insoluble drug, BDD.

Immunologic Aspects of Transplant Management: Pharmacotherapy and Rejection

The intensivist caring for the critically ill transplant patient must be knowledgeable in the management of immunosuppression or have expert help. Critical illness often has a major impact on the absorption and metabolism of immunosuppressive drugs, increasing or decreasing net immunosuppression. Too little immunosuppression brings the risk of graft loss, while too much increases the morbidity and mortality of serious infection. Optimum management often requires the skillful manipulation of dosage and/or routes of drug delivery. In many cases of life-threatening infection, immunosuppression must be discontinued altogether and restarted prior to significant graft injury. The cost of miscalculation is very high. Loss of a renal, pancreas, or small bowel transplant is tragic, while loss of a heart, lung, or liver is usually fatal. Unfortunately the management of immunosuppression is becoming more complex. As the field of transplantation matures, new immunosuppressants are being introduced. Also, more experience and growing numbers of clinical trials are making the required knowledge base ever larger. Each type of transplant has its own set of evolving immunosuppression strategies. This review presents the basic mechanisms of the most widely used drugs and the dangers of immunosuppression. The drugs are then discussed in the context of liver, small bowel, kidney, pancreas, heart, and lung transplantation. Finally, a brief section on the practical pharmacokinetics of the drugs is presented.

Nebulizer-compatible liquid formulations for aerosol pulmonary delivery of hydrophobic drugs: glucocorticoids and cyclosporine

This review discusses pulmonary delivery of glucocorticoids and cyclosporine in pharmaceutically acceptable organic solvents and liposomes, as well as in micellar solutions and microemulsions, by means of liquid aerosols generated by nebulizers. The review points out the importance of a variety of parameters for successful treatment of immunologically mediated lung diseases by inhalation of drug containing aerosols with particular references to physico-chemical properties of formulations, aerosol parameters, pharmacokinetics, and lung deposition in experimental animals and humans. The prospects for the use of these types of formulations for clinical treatment of asthma, lung transplant rejection processes and other lung diseases are summarized.